Skip navigation and go directly to main content.
Chronic Care Clerkship - Conjoint 690

Introduction to Chronic Pain Clinical Focus

"A unified system of knowledge is the surest means of identifying the still unexplored domains of reality...Historians of science often observe that asking the right question is more important than producing the right answer.  The right answer to a trivial question is also trivial, but the right question, even when insoluble in exact form, is a guide to major discovery."
          E. O. Wilson, Consilience, 1998

"The problem is simply that most doctors aren't well prepared to manage pain.  And who enjoys doing something that they aren't trained to do?"
          Scott Fishman: Listening to Pain, 2006

"It is of the highest importance in the art of detection to be able to recognize out of the number of facts which are incidental and which vital.  Otherwise your energy and attention must be dissipated instead of being concentrated."
          A. C. Doyle: from Sherlock Holmes, The Reigate Squire

"If it was simple, word would have gotten around."
          Jacques Derrida, 1988

 

Everyone knows what "pain" is, since all people have had some personal experience with painful injuries and conditions.  This does not make us familiar with the problem of "Pain," when a pain extends without remission for months to years, or, when it has become "chronic."  Our own experiences with pain can mislead and bias us when we encounter patients with continuing persistent Pain.

Chronic non-cancer pain is a very significant problem for patients, their families, their work places, the health care system of delivery and payment, and for doctors of all specialties.  Medical management of chronic pain involves all medical, surgical, and behavioral specialties, but has an especially large impact in all areas of primary care.

Epidemiology of chronic pain:

  • Pain is primary complaint in 40% primary care visits
  • ~30% people report pain during any given day
  • 70% patients with persistent pain managed by PCP
  • Only 2% of these patients see a Pain Specialist

Common Pain Disorders by presenting Site:

  • Headache: 45.2%
  • Spinal/Axial Pain: 47.8%
  • Osteoarthritis: 41.7%
  • Chest: 28.9%
  • Widespread Pain: 17.5%

The suffering from chronic pain is a challenge for patients beyond the pain itself.
Patient responses to recent survey found:

  • My doctor doesn't think my pain is a problem: 20%
  • My doctor doesn't ask me about my pain: 22%
  • I don't get enough time to talk to my doctor about pain: 23%
  • No one believes my pain is as bad as it is: 29%
  • My doctor would rather treat an illness than my pain: 43%

There are also entrenched erroneous patients beliefs:

  • Chronic Pain = Prolonged Acute Pain
  • Chronic pain can be cured, "If only they knew what was wrong with me"
  • Surgery will fix most problems
  • Opioids will make me look, behave like, or become an addict

Challenges for doctors often involves long-standing biases and prejudices about chronic pain patients:

  • 15% PCP feel comfortable treating chronic pain
  • 80% have a negative attitude toward use of opioids
  • 41% wait for patients to request for pain Rx

Many doctors also misunderstand chronic pain:

  • Treat just the "pain site" and the pain will resolve
  • Surgeons are needed for painful spines and joints
  • My nice patient won't become an addict
  • Requesting a drug by name means "drug-seeking"
  • Chronic pain patients will ruin my day

Primary care doctors have the training and skills to care for many chronic conditions well, such as diabetes, coronary artery disease, hypertension, and depression.  Yet, they feel unable to provide continuing care for chronic pain even with the training and capability necessary to do so, since primary care doctors routinely:

  • Conduct patient-centered interviews and examinations
  • Diagnose & manage acute and chronic medical conditions
  • Perform biopsychosocial diagnosis & management
  • Manage pharmacotherapy of ordinary and complex chronic diseases
  • Provide entry point to supportive & rehabilitative care
  • Offer referral source for subspecialty consultation
  • Are able to follow and carry out specialist advice

There are, however, a number of specific deficiencies in the "toolkit" for the proper care of chronic pain:

  • Scope of training has been limited/absent
  • Linear evidence-based data incompletely addresses complex pain disease and management
  • Most guidelines advise multidisciplinary pain centers only for aberrancy, such as major psychiatric or behavioral problems, or for detoxification and/or addiction management
  • Incomplete awareness of the value and approach for PT/OT/Vocational/CAM interventions
  • Very limited understanding of interventional options, particularly in the area of peripheral mechanisms of pain

Doctors recognize the value of continuity of care, which enables trustful listening and attentive care.  Chronic pain management similarly relies on the "whole story" narrative, psychosocial context, long-term outcome assessment, and risk assessment of treatments provided.  Practically, chronic pain diagnosis and treatment is usually quite challenging from the perspective of difficult diagnosis and clinical management, since previous measures and specialty assessments have not worked.  Chronic pain is, as a result of this challenge, rewarding to manage.  A physician can learn to develop the skills necessary to treat chronic pain patients, most who have been told, often many times by many experts, that "there is nothing more I can do for you."

 

EDUCATIONAL EXPERIENCES AND EXPECTATIONS:

The first day and the last day of the rotation is an all-day Didactic Session with all Chronic Care Clerkship students, including Palliative Care, Geriatrics, and Rehabilitation Medicine tracks.

Each Monday, Chronic Pain Track students will meet as a group to present clinical cases.  The focus of these sessions is to facilitate skill building in:

  1. Obtaining and presenting the patient narrative history
  2. Risk factor assessments
  3. Physical exam finding and presentation
  4. Biopsychosocial assessment
  5. Goals and outcomes
  6. Treatment options
  7. Specific topic(s) of educational importance

At the UWMC Center for Pain Relief, students will be assigned specific outpatient multidisciplinary pain clinic direct patient care experience.  This will include:

  1. New Pain Patient consultations (minimum 1/week)
  2. Follow-up Pain patient consultations (several daily)
  3. Participate in Behavioral evaluations of Pain patient (1 day/week)
  4. Participate in Vocational assessments and follow-ups (~1 day/week)
  5. Observation of interventional anesthesia procedures (TBA)

Free time on Friday AM (to be arranged with track director) for:

  1. Assigned case write-up:
    • Selected patient from clinic experience
    • In depth review of patient medical records pertinent to their chronic pain condition
  2. Self-study
    • Literature review and summary of topic(s) relevant to chronic pain as it relates to your chosen case
  3. Interviewing the patient and family during at least one home visit
  4. Self-directed Pain Division experiences, when possible (TBA)
    • Additional observation of interventional anesthesia procedures
    • Participation with UWMC Acute Pain In-patient service
    • Observation of Cancer Pain clinic at Seattle Cancer Care (off-site)

Conferences and Lectures Schedule:

  • 2nd, 3rd, and 4th Mondays; every Tuesday and Thursday; and 1st, 2nd, and 3rd Fridays 7:00-7:45am Resident Lecture Series at UWMC AA-103A.
  • Tuesday 5:15-6:15pm Seminars in Pain Medicine; at Roosevelt-2 Conference room A/B.
  • Wednesdays 6:30-7:30am Anesthesia Grand Rounds (optional); located at UWMC D-206.

Pain Track Schedule

WEEK 1

  • MONDAY
    All day full clerkship Group Didactic Session
  • TUESDAY
    7:00-7:45 Resident Lecture - UWMC AA-103A
    8:00-9:00 Intro to Pain Clinic - Center for Pain Relief
    9:00-4:00 Behavioral Medicine Clinic - Center for Pain Relief
    5:15-6:15 Seminars in Pain Medicine - Roosevelt-2 Conference room A/B
  • WEDNESDAY
    6:30-7:30 Anesthesia Grand Rounds (optional) - UWMC D-206 
    8:00-5:00 Pain Clinic - Center for Pain Relief
  • THURSDAY
    7:00-7:45 Resident Lecture - UWMC AA-103A
    8:00-5:00 Pain Clinic - Center for Pain Relief
  • FRIDAY
    7:00-7:45 Resident Lecture - UWMC AA-103A
    8:00-12:00 Self study/presentation preparation/Home visits/TBA
    1:00-5:00 Pain Clinic - Center for Pain Relief

WEEK 2

  • MONDAY
    7:00-7:45 Resident Lecture - UWMC AA-103A
    8:00-12:00 Pain Clinic - Center for Pain Relief
    1:00-5:00 Group discussion; TBA activity - Center for Pain Relief
  • TUESDAY
    7:00-7:45 Resident Lecture - UWMC AA-103A
    8:30-4:00 Behavioral Medicine Clinic - Center for Pain Relief
    5:15-6:15 Seminars in Pain Medicine - Roosevelt-2 Conference room A/B
  • WEDNESDAY
    6:30-7:30 Anesthesia Grand Rounds (optional) - UWMC D-206
    8:00-5:00 Pain Clinic - Center for Pain Relief
  • THURSDAY
    7:00-7:45 Resident Lecture - UWMC AA-103A
    8:00-5:00 Pain Clinic - Center for Pain Relief
  • FRIDAY
    7:00-7:45 Resident Lecture - UWMC AA-103A
    8:00-12:00 Self study/presentation preparation/Home visits/TBA
    1:00-5:00 Pain Clinic - Center for Pain Relief

WEEK 3

  • MONDAY
    7:00-7:45 Resident Lecture - UWMC AA-103A
    8:00-12:00 Pain Clinic - Center for Pain Relief
    1:00-5:00 Group discussion; TBA activity - Center for Pain Relief
  • TUESDAY
    7:00-7:45 Resident Lecture - UWMC AA-103A
    8:30-4:00 Behavioral Medicine Clinic - Center for Pain Relief
    5:15-6:15 Seminars in Pain Medicine - Roosevelt-2 Conference room A/B
  • WEDNESDAY
    6:30-7:30 Anesthesia Grand Rounds (optional) - UWMC D-206
    8:00-5:00 Pain Clinic - Center for Pain Relief
  • THURSDAY
    7:00-7:45 Resident Lecture - UWMC AA-103A
    8:00-5:00 Pain Clinic - Center for Pain Relief
  • FRIDAY
    7:00-7:45 Resident Lecture - UWMC AA-103A
    8:00-12:00 Self study/presentation preparation/Home visits/TBA
    1:00-5:00 Pain Clinic - Center for Pain Relief

WEEK 4

  • MONDAY
    7:00-7:45 Resident Lecture - UWMC AA-103A
    8:00-12:00 Pain Clinic - Center for Pain Relief
    1:00-5:00 Group discussion; TBA activity - Center for Pain Relief
  • TUESDAY
    7:00-7:45 Resident Lecture - UWMC AA-103A
    8:30-4:00 Behavioral Medicine Clinic - Center for Pain Relief
    5:15-6:15 Seminars in Pain Medicine - Roosevelt-2 Conference room A/B
  • WEDNESDAY
    6:30-7:30 Anesthesia Grand Rounds (optional) - UWMC D-206
    8:00-5:00 Pain Clinic - Center for Pain Relief
  • THURSDAY
    7:00-7:45 Resident Lecture - UWMC AA-103A
    8:00-5:00 Pain Clinic - Center for Pain Relief
  • FRIDAY
    All day full clerkship Group Didactic Session

RECOMMENDED READINGS FOR THE CHRONIC PAIN FOCUS:

Pain: Moving from Symptom Control toward Mechanism-Specific Pharmacologic Management

Plasticity and Functional Recovery in Neurology

Fibromyalgia: A Disorder of the Brain?

Complexity & Healthcare

The Cerebral Signature for Pain Perception and Its Modulation

Antidepressants for the Treatment of Chronic Pain

 

Top of Page